Changing the Paradigm of In-Hospital Cardiopulmonary Resuscitation With Informed Assent

• Depression [ Time Frame: Baseline (day of intervention) and 2 weeks after intervention ] [ Designated as safety issue: No ]
  Patients' and family members' symptomes of depression will be measured by the PHQ-8 questionnaire.
• Anxiety [ Time Frame: Baseline (day of intervention) and two weeks after intervention ] [ Designated as safety issue: No ]
  Patients and families will complete the GAD-7 questionnaire, a measure of generalized anxiety disorder.
• Physician Order for Life Sustaining Treatment (POLST) [ Time Frame: Baseline (day of intervention) and 2 weeks after intervention ] [ Designated as safety issue: No ]
  Participants who expressed a preference to be DNR will be asked to complete a POLST form by their physician. It will also be explained that this can be changed any time the status changes.
• DNR status preference [ Time Frame: Two weeks after the intervention ] [ Designated as safety issue: No ]
  The difference in DNR status preference between patients in the control and invervention group at two weeks after the intervention.
• Report on acceptability of the informed assent approach [ Time Frame: Within couple of hours (up to 2 weeks) after intervention ] [ Designated as safety issue: No ]

  The following questions will be asked:

  1. How helpful was this approach to discussing CPR with respect to CPR decisions?
  2. Would you recommend this approach to discussing CPR for other patients who have serious illnesses?
• Assessment of DNR status change or intervention follow-up from primary physician [ Time Frame: Three months after the intervention ] [ Designated as safety issue: No ]
  Contact the physician for each patient at 3 months after the study visit to determine whether there are changes in the DNR status or if the physician has talked with the patients about the status since the study visit.
• Resource utilization [ Time Frame: Up to 6 months after intervention or until death ] [ Designated as safety issue: No ]
  Record resource utilization for participants that includes hospitalizations, ICU care, use of hospice etc by medical record review.

Outcomes after in-hospital cardiopulmonary resuscitation (CPR) are very poor, particularly in patients with oxygen dependent chronic obstructive pulmonary disease (COPD) or metastatic cancer. Recent work found that in-hospital CPR is being performed more often before death with unchanging survival and that fewer CPR survivors are being discharged home, thus suggesting that CPR is increasingly performed without benefit and that the burden of this ineffective treatment is increasing. Unlike other medical procedures, CPR has become the default provided to all patients even those with tremendously poor outcomes. It is time to change the paradigm of CPR. Through comparing an innovative "informed assent" approach toward in-hospital CPR (informing patients that their underlying chronic illness makes outcomes of CPR so poor that CPR is not performed while allowing them to disagree) versus usual care in a group of chronically ill patients with reduced life expectancy, the investigators aspire to demonstrate that CPR delivery can be reduced. And in addition that DNR status increases, while preserving patient quality of life and decreasing the burden of this ineffective treatment to both patients and families. If effective, this informed assent intervention has the potential to revolutionize how the investigators discuss CPR with the investigators chronically ill patients.

• Oxygen Dependent COPD
• Advanced Malignancy

• Behavioral: Informed Assent
  Patients receive informed assent approach toward in-hospital CPR outcomes. Patients are informed that their underlying chronic illness makes outcomes after CPR so poor that CPR is not performed while allowing them to disagree.
• Behavioral: Informational Brochure
  An informational brochure about CPR will be given without a discussion with a physician.

• Active Comparator: Informational brochure
  Patients receive an informational brochure
  Intervention: Behavioral: Informational Brochure
• Experimental: Intervention
  Patients receive physician-directed informed assent intervention regarding CPR and informational brochure.
  Intervention: Behavioral: Informed Assent

Inclusion Criteria:

• 18 years or older
• Oxygen dependent COPD or Advanced Malignancy
• Life expectancy of less than two years

Exclusion Criteria:

• Subjects who have already firmly decided to undergo CPR
• Subjects enrolled in a hospice program
• Subjects unable to speak English
• Subjects incapable of making their own decisions at the time of enrollment
• Subjects cared for by the study investigator